Insufficient Nursing and Direct Care Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple days with no RN hours and several shifts without 24-hour licensed nursing coverage, according to PBJ Staffing Data Reports from October through December 2024. The Quality of Care Monthly Reports for January, February, and March 2025 further documented numerous shifts across all times of day with insufficient direct care staff for the reported resident census. Interviews revealed that the facility relied almost entirely on agency staff for CNAs, CMAs, and licensed nurses, with no core staff RNs consistently covering specific shifts. The Director of Nursing had resigned in April 2025, and the Assistant Director of Nursing was the only full-time core staff nurse, while the MDS coordinator was shared with another facility. CNA staff reported that, in addition to their care duties, they were often responsible for housekeeping tasks such as emptying trash, cleaning bathrooms, and sweeping floors, especially when housekeeping staff were unavailable or their hours were uncertain. Staffing levels fluctuated based on resident census and staff call-ins, sometimes resulting in only one CNA per hall. The administrator confirmed the lack of consistent RN coverage and the heavy reliance on agency staff, with RN shift coverage varying week to week and no core staff RNs assigned to regular shifts.